| WHO MANAGES YOUR MANAGED CARE? |

Trojan Professional Services empowers you to stay on top of Managed Care with minimal stress.

Trojan summarizes the most critical features of each plan, providing you with:

n Co-payment schedules

n Supplemental payments

n Visit fees/Broken appointment fees

n Pertinent lab reimbursement information

n Highlights of exclusions (Notes and Limitations)

n Referral information

Trojan also provides specific exclusions and limitations that are unique to each plan,

including perio frequency guidelines and detailed specialty referral information.

This information is displayed in an easy-to-read format that can be printed for your

patient’s chart. Also listed are important fees and co-pays to be collected at

time of visit. Supplemental information is listed when available.

Centralize Your Managed Care Plans

Eliminate the laborious task of having to pull a manual, find a plan, find the plan exclusions

and limitations to determine their benefits.

With Trojan, there’s no need to go to different places for co-pays, supplemental payment,

and yet another place for exclusions, limitations, and specialty referrals.

Trojan’s Managed Care program is compatible with any Windows-based computer.

It is also Internet compatible, so updates can be done online, although Internet is

not required.

800-451-9723www.trojanonline.com

Managed CareAn extension of your staff

How to Reach UsTrojan’s Service Department: 800-633-3060. Office hours: Monday through Thursday,6 a.m. - 5 p.m. PST, and Friday from 6 a.m. - 4 p.m. PST. (We are closed every Friday 1 - 2 p.m. for training, to continually improve our service to you.)

Managed Care BenefitsAn extension of your staff

Trojan ID M007255Plan Number A1234Plan Name A1234Carrier Dental HealthEligibility Phone (800) 555-9999 Administrative Phone: (800) 555-9999

Payment Base Schedule

Limitations Tx. not listed not covered, but can be done at addl. pt. cost or alternate provision applies. See notes.Cap Fee Yes.Visit Fee $5.Supplemental Pmt Yes. See schedule for General DDS. Minimum chair hour rate guaranteed by Dental Health. See notes.Lab Reimbursement $80 additional co-pay, per unit, for procelain fused to metal crowns or pontics on molar teeth. See notes.Broken Appointment Established office policy if not notified within 24 hours.C.O.B. The policy of the other plan determines which plan is primary. Patient responsible up to this fee schedule.Specialty Referrals Perio if pockets are 5mm or more, Endo, O.S. with pathology, Pedo to age 7 & Ortho.Pre Approval General Dentist refers to Specialist for consult. Specialist must pre-auth Perio, Pedo & Oral Surgery.Xrays Required Send to specialists for referrals.Perio Charts Required Specialist when pre-authorizing treatment.Dependent Coverage Verify eligibility test.FMX Frequency 1 FMX or Panorex per 36 months. Limitation may vary for state of Texas, verify with administrator.Prophy Frequency 1 x 6 mos.,Verify frequency for TX. D4910 limited to 2 within the 1st 12 mos. after active therapy.

See notes.Flouride To age 19. Verify limitation for Texas residents. 1 per 6 months.Sealants To age 14. Verify limitation for Texas residents. No frequency limit given. Virgin primary & permanent

molars within 4 years of eruption.Perio Limitations Perio scaling & root planing limited to 4 quads per 12 consecutive months. See notes.Prior Extractions Cov Yes.Prosthetic Replacement 5 years. Limitation does not apply for crowns & bridges in California if medically necessary. See notes.Reline Frequency Once per arch every 36 months.General Anesthesia Not covered.T.M.J. Not covered.Ortho Co-pay $1500 to age 19, $2000 age 19 & over. Patient co-pay $150 for records and treatment plan.

Pre-orthodontic visit fee $50. Retention fee $300.Treatment period 24 months. Ortho age verifywith eligibility.Additional patient co-pay if active treatment exceeds 24 months.

Notes & Limitations Co-pay zero for D1110/D1120 with $1.50 supplemental from Dental Health, addl. tx. copay $41 for D1110, $30 for D1120. Codes D2740, D6245 or D6740 not a benefit for molar teeth copay UCR. D4355 1x lifetime, D4910 2 x1st 12 mos. Patient co-pay $30 for crown exposure of impacted or unerupted tooth to aid eruption, use code D7281. No charge for first 4 adjustments on dentures or partials if within 6 months of insertion. Denture copay includes the cost of characterization. Some tx. may fall under “alternate provision” see manual. 6/6+ units of crown/bridge in same treatment plan requires complex rehabilitation. Addl. co-pay $125 per unit.

TROJAN MGD CARE - SO CA

Patient Name SampleMail Encounters / Dental HealthPre-Approvals to: Various Locations, See Notes

Managed Care BenefitsAn extension of your staff

800-451-9723www.trojanonline.com